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UNIFIED PROGRAMCOI:SULaMYEI:i'Q-Rl.� D� <br /> 1JNIAMC-1,0UIi3ST111LIWE'°'A '!, � <br /> G,ft;U:LITG )t,WAUTi��F ,ICATION -- FiLC -1eYIi�'Fvlc'veLuON <br /> (floc toren Per)aolilry) <br /> TYPE OF ACTION 1 L] 1.NEW PERMIT' [j i.CHANGE OF INFORMA7!:n C_ :' Pi 1!lm/1 rd'�';"F tCU TT+ C;nSGFr' Im <br /> (Cluck e«4m wly) ' [] 3.RENEWAL PERMIT ❑ 6,TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> _. <br /> -........ <br /> 3 FAC-axlYINFOR"I'%OI4 <br /> TOTAL NUMBER OF LISTS AT FACBSI'Y ° FACQ.ITY ID 4 <br /> (.A!genry 7Jre fhov) - 0! <br /> BUSMESS NAME(Sera.a F'ACaAN n wD"-Lew a wx) ). <br /> �1 <br /> BUSINESS—SITE ADDRESS ... log. CIT,Y la. <br /> �' �Sz _ ��CG•�j/,C/i°.LGliC/� ClSZ_- 1 y � <br /> FACILITY TYPE Vt.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ao;' IS the facility located on Indian Rgservation or 405. <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust Iona? ❑Yes o <br /> _ . _ II PROPRRI*OU+Ni•;R INFORMATION <br /> PROPERTY OWNER NAME . ..PHONE <br /> MAILING ADDRESS 499. <br /> C 10. STATE oar. ZIPCODE 411. <br /> III. uick,0PE!t#.ORY0ORMk"0i4' <br /> TANK OPERATOR NAME 4 1. PHONE aza•2 <br /> MAILING ADDRESS _—— -- — _ ———--— ass <br /> CITY --— __- T a TiTATF 42&5 ZIP CODE 428-6 <br /> - - — <br /> M TAN'_:0W' RL1WC,RME"YON <br /> TANK OWNER NAME _._.. -- ,.. - <br /> ,14. 1 NC qEals. <br /> ING ADDRESS 416. <br /> CRY / 417. ST,7 ate. ZIPCODE 419. <br /> OWNE).TYPE: u ,..LC^L•w' nvniiCYiUISIKICT 1 1 5.COI rN Ancr.!CY u o.al'AI'E AGENCY 420. <br /> ❑ 7..'Y,`ERAL AGENCY ❑ S.NON-GOVERNMENT <br /> — - - >IJ. rtISTS7ORAGS- <br /> TV(TIC)HQ44- lar --sCall the State Board of Equalization.Fuel Tax Division,if there aro qucattom. 421. <br /> ——— � VI.PEIIMIT�OLDLit INFQ'ltltiil't'IOd117 <br /> len;peruit and arced legal notifications aM_!_�(e: u :••.,C....i GwrieR U 4.TANK OPERATOR 40 <br /> .TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPE)A:aJA OF JIVbrON,SECTION,OR OFFICE(Required For Public Agencies Only) ' <br /> VII.APPLICANT SIGNATURE <br /> CER71'ICA1::N: .'ct rd(,that the infero mdoa rov M beds H trm aamrate and in <br /> %Utom ce with Wreesemta. <br /> APPLD's:+T SP rN,TU / DATE : 4 PHONE <br /> P11C+ TNAM•(print) 41& APPLICANT TITLE <br /> C <br /> UPCe US-A#".(13/2007) <br />